Rheumatologists Get Treat-to-Target Goals for RA

Action Points

Explain to interested patients that the goal of treatment in rheumatoid arthritis today is sustained clinical remission, which may require frequent assessment and changes in treatment.

Clinical remission should be the primary goal of rheumatoid arthritis treatment, according to new recommendations from an international task force that spell out benchmarks toward reaching that target.

Although remission -- defined as the absence of signs and symptoms of significant inflammatory disease activity -- may not be possible for all patients with longstanding disease, the prevention of progression of joint damage and reversal of physical disability is "a pivotal goal for the new decade," stated Josef S. Smolen, MD, of the Medical University of Vienna, and colleagues.

In many other areas of medicine, such as in the care of patients with diabetes and hypertension, treatment targets have been established and widely adopted, resulting in improved outcomes.

This approach has not yet been accomplished in rheumatoid arthritis, the task force wrote in the April issue of Annals of the Rheumatic Diseases, despite the "paradigmatic changes" seen in recent years in diagnosis and treatment.

These changes include the early institution of disease-modifying therapy, the development of composite measures for accurate assessment of disease activity, and the licensure of the biologic agents, which "have enabled the attainment of unprecedented outcomes," the panel wrote.

To incorporate these advances and provide guidance to clinicians in treatment-to-target therapy for rheumatoid arthritis, the task force steering committee undertook a systematic literature review and held discussions with more than 60 experts from around the world.

They formulated these overarching principles for the management of rheumatoid arthritis:

Treatment must be based on shared decisions by patients and rheumatologists.

The primary goal is maximization of long-term health-related quality of life through symptom control, prevention of structural damage, and normalization of function.

The most important way to reach these goals is through avoidance and abrogation of inflammation.

The task force then established a series of specific recommendations, led by the assertion that sustained clinical remission should be the target.

In defining remission, the task force used the phrase "significant inflammatory disease activity" to acknowledge that some residual or isolated joint tenderness might remain. However, they noted, significant joint swelling and elevated C-reactive protein are not acceptable, in that they reflect active inflammation.

For patients with advanced disease, considerable joint damage, and multiple treatment failures, remission may not be realistic, the task force acknowledged. For these patients, the target can be a sustained low disease activity state.

Another recommendation referred to the necessity of using validated composite measures to assess disease activity.

Those might include the disease activity score (DAS), the DAS with 28-joint count (DAS28), and the simplified and clinical disease activity indexes (SDAI, CDAI). The choice of which to use is the clinician's, and may be influenced by comorbidities and other patient factors.

Once treatment is begun, ongoing clinical evaluations and treatment adjustments are required according to response, but at least every three months.

For instance, if patients do not reach at least a state of low disease activity by three months, treatment should be changed. This need not necessarily be a switch in drugs, but could be a new dosage.

And because disease progression can occur within weeks in patients with high disease activity, these patients should have more frequent assessments, possibly even monthly, until remission (or low disease activity with longstanding disease) is reached.

Once sustained remission has been achieved, examinations may be less frequent, although patients must be told to see their rheumatologist if they experience symptom changes.

Finally, the patient must be informed about the target, the strategy planned for achieving it, and the various therapeutic options that can be used under the guidance of the rheumatologist.

The task force noted that their recommendations do not take into account financial constraints or access to the various therapies, which may influence the proportion of patients reaching treatment targets.

Nonetheless, adherence to specific treatment strategies may improve outcomes even if only the more affordable and accessible agents are used.

The recommendations, the authors concluded, "are aimed at all stakeholders: patients who are informed by these statements on the optimal strategies to prevent or contain damage and disability; rheumatologists and other health professionals who may further their drive to do the best for the patients; and also official bodies such as governments or payers which may wish to use this document as a reference for the assessment of success in treating patients with [rheumatoid arthritis] in their environment."

This work was supported by an unrestricted educational grant from Abbott Immunology, but the company was not involved in the program or development of recommendations. At the end of the voting process, the Expert Committee was asked to vote in an anonymous fashion if they felt they had been influenced by the sponsoring of the event by Abbott. This ballot resulted in an agreement of 8.7/10 that they did not consider that the fact that Abbott was sponsoring this program created a bias.

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